For such little rocks, gallstones can cause a lot of issues. They are very common and are present in a quarter to a third of Australian adults over 50. Although most people do not require treatment, some people with gallstones need to have their gallbladder removed through a surgical procedure called a cholecystectomy. Almost 11,000 cholecystectomies were performed in Queensland in 2012-2013.
What are gallstones, exactly?
When you consume a meal, the food needs to be broken down and absorbed in your gastrointestinal tract, commonly known as the gut. Bile is a substance produced by the liver and is essential for the breakdown and absorption of fats from foods, and fat-soluble vitamins (A, D, E, and K). Bile is stored within the gallbladder and released into the gut when you eat. The gallbladder lies below the liver in the right upper part of your abdomen. It is linked to the liver, pancreas and gut through a series of ducts called the biliary tree. Gallstones are solidified particles of cholesterol and/or bile pigment that develop within the gallbladder. They are caused by the imbalance between the components of bile and can vary in size from a grain of sand to a large pebble.
Having one or more of the following factors increases your risk of developing gallstones:
• Female gender
• Increasing age
• Obesity
• Family history of gallstones
• Medical conditions, such as diabetes and liver cirrhosis
• High-calorie, low-fibre diets
• Certain medications
• Pregnancy
• Rapid weight loss
Lifestyle changes that may reduce the likelihood of developing further gallstones include regular exercise, following a low calorie, high fibre diet, and maintaining a healthy weight.
Are gallstones painful?
The majority of people with gallstones are pain-free and may only discover they have the condition incidentally through an imaging test. However, gallstones do cause pain if a stone becomes trapped within the neck of the gallbladder or the pancreas or within the biliary tree. This can create an obstruction and possibly lead to an infection.
Gallstone pain is known as ‘biliary colic’. It is typically experienced as a severe pain in the right upper abdomen that tends to last for hours. It may radiate into the right shoulder blade or back and can occur more frequently at night. Eating a fatty meal stimulates release of bile by the gallbladder and may also trigger the pain. The pain subsides after some time but many people feel nauseated and vomit during these episodes. If an individual suffers from one attack of biliary colic they are at risk of experiencing further episodes.
People with gallstones may develop blockage and inflammation of the gallbladder (cholecystitis), the biliary tree (cholangitis), or the pancreas (acute pancreatitis). These conditions cause constant severe pain, fevers and chills and are medical emergencies. People require hospital admission, intravenous fluids, pain relief and antibiotics. If gallstones block the flow of bile, the individual may develop the yellowing of the skin and eyes known as jaundice. People with pancreatitis often have constant, severe abdominal pain that goes into their back. If the blockage and infection are not treated quickly enough, the results, including organ rupture, may be fatal.
How do I know if gallstones are causing my symptoms?
A number of tests can be performed to look for gallstones and determine what treatment options may be suitable. Blood tests determine how the liver is functioning and whether an infection is developing. An abdominal ultrasound can confirm the diagnosis. This radiation-free test visualises the solid abdominal organs and is the first-line imaging test for gallstones. Other tests include an abdominal CT and MRI scan.
How should my gallstones be treated?
The answer depends on your personal situation. People who do not have pain or other symptoms do not require immediate treatment. They can be managed expectantly, that is, they can seek appropriate medical treatment if and when they develop symptoms. However, if they have had biliary colic or infection (cholecystitis, cholangitis, or pancreatitis), their doctor is likely to recommend removal of their gallbladder with the offending stone.
Although the gallbladder is an important organ, it is not essential and can be removed in individuals with biliary colic or complications. This is usually done as a minimally invasive ‘keyhole’ operation called a laparoscopic cholecystectomy.
Whilst the person is under anaesthesia, small incisions are made in the abdomen to allow entry ports for a small video camera and the surgical instruments. Carbon dioxide gas in gently inserted through these ports to distend the abdomen and make it easier to see everything. All the surgery is done through the ports. The gallbladder is carefully released from the surrounding organs and removed. After this, the gas is removed from the abdomen and the ports are closed with stitches and dressings.
The benefits of removing the gallbladder laparoscopically rather than as an open procedure include:
– Smaller scars and a superior cosmetic outcome
– Shorter hospital stay
– Reduced blood loss and risk of infection
– Reduced tissue trauma, and therefore reduced pain and discomfort
– Reduced need for pain relief side effects, such as constipation)
– Faster recovery and return to work, with 2-3 weeks to full recovery, instead of 4-6 weeks.
In some cases, it may not be possible to remove the gallbladder through a port. In this situation, the surgeon may need to make a larger cut in the abdomen to safely remove the gallbladder. Converting a laparoscopic operation to an open procedure is not a complication, but a clinical decision made in the best interests of the patient.
As with any procedure, there is the risk of complications. Some people develop increased bowel frequency after the operation, but it tends to be temporary. Other complications are rare – bile leak occurs in 1-2% of patients and may require further surgery, and a bile duct injury occurs in up to 0.5% of patients.
If a stone is lodged outside the gallbladder in the biliary tree it may not be possible to remove it at the time of the operation. In that case the may require a second procedure called endoscopic retrograde cholangiopancreatography (ERCP). This is a procedure that can be used to diagnose and treat gallstones in the bile duct. Under sedation, a gastroenterologist passes small flexible fibre-optic camera through your mouth to view the gut, together with dye and a specialised radiation-free imaging machine. The gallstones are retrieved with a tiny basket and/or balloon via the scope.
Conclusion
Gallstones are a common condition. They only need to be treated if they are causing symptoms. There are safe and effective ways to treat gallstones and prevent their recurrence. Talk with your doctor about the most suitable option for your individual situation.